Comprehensive Initial Exercise Physiology Assessment

Referral type: Referred under a Medicare Chronic Disease Management (CDM) plan with 5 authorised sessions, of which this is session 1 of 5.

Reason of referral: Referred by GP for structured exercise intervention to manage bilateral knee osteoarthritis (OA) and T2DM. Insidious onset of bilateral medial knee pain over 3 years, worsening over the past 6 months. Presents as a dull ache (4/10 VAS) with morning stiffness (< 30 mins), increasing to sharp pain (6/10 VAS) on weight-bearing flexion. Aggravating factors:

• Descending stairs
• Prolonged walking (> 15 mins)
• Sit-to-stand transfers from low surfaces Relieving factors:
• Rest and offloading
• Local heat application
• Paracetamol

Subjective

Medical History

• Type 2 Diabetes Mellitus (diagnosed 2018)
• Hypertension (diagnosed 2016)
• Hyperlipidaemia (diagnosed 2016)

Musculoskeletal

• Bilateral knee OA (diagnosed 2021, R > L): Medial compartment joint space narrowing. Currently managed with PRN analgesics and activity avoidance.
• History of right arthroscopic partial medial meniscectomy in 2012 with full functional recovery at the time. Bilateral knee X-rays (10/09/2023) demonstrated moderate medial compartment OA on the right and mild-to-moderate OA on the left.

Medications

• Metformin 1,000 mg PO BID for glycaemic control in T2DM, keeping HbA1c stable at 7.1 %.
• Perindopril (Coversyl®) 5 mg PO OD for hypertension management, maintaining normotensive resting BP.
• Atorvastatin (Lipitor®) 20 mg PO ON for lipid control.
• Paracetamol (Panadol Osteo®) 1,330 mg PO TID PRN for knee OA pain management.
• Patient reports no known drug allergies (NKDA).

Social History

• Lives in a single-storey brick home with his wife, has supportive local family, and owns one small dog.
• Retired accountant; volunteers at the local community mens' shed one morning per week.
• Ex-smoker (ceased 2005) and consumes 2 standard alcoholic drinks on weekends.

Exercise History

Current: Walks the dog on flat suburban footpaths 2 times per week for 15 minutes at a slow pace, limited by right knee ache.

Previous: Played social lawn bowls twice weekly and walked 45 minutes daily prior to symptom escalation 6 months ago.

Barriers

• Fear of exacerbating knee joint damage (kinesiophobia)
• Low self-efficacy regarding resistance training

Goals

• Walk the dog for 30 minutes continuously on flat ground with knee pain remaining ≤ 2/10 VAS within 6 weeks.
• Complete 3 sessions per week of a home-based lower limb strengthening program independently over the next 4 weeks.
• Ascend and descend a standard flight of 12 stairs reciprocally without holding the handrail within 8 weeks.

Objective

• Resting Vitals: BP 128/78 mmHg, HR 72 bpm, SpO2 98 % on room air. Anthropometrics: Height 176 cm, Weight 92.5 kg, BMI 29.9 kg/m², Waist circumference 104 cm.
• Knee AROM: Right knee flexion 0–110° (end-range ache), Left knee flexion 0–120° (pain-free).
• Functional Assessments: 30-Second Sit-to-Stand test: 9 repetitions (utilised armrests, reported 4/10 R knee pain). 6-Minute Walk Test (6MWT): 360 m (RPE 12/20, stopped once at 4 mins due to 5/10 R knee pain). Single-leg balance (eyes open): R 8 s, L 14 s.
• The Knee Injury and Osteoarthritis Outcome Score (KOOS) was administered today, scoring 54/100, and is filed with the current date (14/05/2024).

Treatment

• Provided pain physiology education regarding OA, clarifying that mild discomfort during exercise (≤ 3/10 VAS) does not equate to structural joint damage.
• Discussed the role of quadriceps and gluteal strengthening in joint offloading and dynamic knee stability.
• Explained the mechanism of muscle contraction-mediated glucose uptake to improve insulin sensitivity in T2DM.
• Home Exercise Program: Aerobic Exercise: Walk 15 minutes on flat ground, 3 days per week at RPE 11–12/20 (light-to-moderate intensity). Resistance Exercises (3 days per week, non-consecutive, RPE 12–13/20):
  • Sit-to-stand from dining chair (with cushioned seat to raise height): 3 sets x 8 reps
  • Supine glute bridges: 3 sets x 10 reps
  • Seated theraband knee extensions (yellow band): 3 sets x 10 reps bilaterally
  • Standing calf raises (supported at kitchen bench): 2 sets x 12 reps Warnings: Cease exercise if sharp knee pain exceeds 4/10 VAS, if joint swelling increases the following morning, or if experiencing symptoms of hypoglycaemia, dizziness, or chest pain.

Assessment

• The patient presents with reduced lower limb muscular endurance and aerobic deconditioning secondary to bilateral knee OA pain and subsequent activity avoidance, which also sub-optimally impacts his T2DM management.
• Subjective history and objective testing demonstrate decreased functional capacity (below age-predicted norms on 30s STS and 6MWT) and reduced right knee flexion AROM, though the patient responded well to initial load modification and education during the session.

Plan

• The client will complete the prescribed Home Exercise Program and record daily adherence and pain responses in an exercise diary, while the clinician will send a summary report to the referring GP.
• The next review is planned in 2 weeks (28/05/2024 at 10:00).
• The patient has an existing appointment with his GP (Dr. A. Smith) on 20/06/2024 for a routine diabetes review, and a podiatry referral was recommended for footwear assessment.
• The exercise plan consists of 3 sessions per week of home-based resistance training and 3 sessions per week of low-impact aerobic walking.
• Progress may be influenced by flare-ups in knee joint symptoms, requiring volume or range-of-motion adjustments at the next review if post-exercise pain persists beyond 24 hours.